43(4): ,2002. Andrija Štampar School of Public Health, Zagreb University School of Medicine, Zagreb, Croatia

Transcription

1 43(4): ,2002 PUBLIC HEALTH Citizens Views on Health Insurance in Croatia Miroslav Mastilica, Sanja Babiæ-Bosanac Andrija Štampar School of Public Health, Zagreb University School of Medicine, Zagreb, Croatia Aim. To examine the citizens attitudes toward health insurance and its reform in Croatia, and their views on private payments for health care services. Method. In 1999 and 2000, we surveyed 500 randomly selected adults from all regions of Croatia, aged 40 years and over. The questionnaire included questions on social health insurance, private payments for health care, and background information. The net response was 393 (79%). The analysis of the data collected included univariate and multivariate analyses to test the differences in the attitudes among sociodemographic and socioeconomic groups. Results. Most interviewed Croatian citizens (83.2%) expressed the opinion that everybody should have access to health care services, irrespective of the health insurance contributions. However, 32.1% agreed that the utilization of services should depend on the payment of contribution; 39.1% believed that the money they contributed to health insurance corresponded to health care services they received; 60.1% agreed that insurance rate should increase proportionally to income. When asked about reforms, more than half (53.4%) thought that the current health insurance covered less benefits than 10 years earlier, whereas more than a third believed that changes offered more choice (36.9%) but less equity (37.7%), and 46% disagreed with the introduction of the basic package of health care benefits and supplementary insurance. About the same percentage of respondents thought that they had already been paying too much for health care out of their own pockets. Conclusion. Citizens in Croatia do not hold a positive opinion on health insurance reform. They fear the changes would bring about limitations in their social rights and increase their financial burden. Key words: Croatia; financing, government; health care reform; insurance, health; public opinion Over the last 10 years, social health insurance in Croatia has been continually changed, arousing further public, professional, and political debates on the need for a more radical approach. Eventually, a new strategy for the reform of the health care system and health insurance was adopted (1). The government decided to change the social health insurance primarily because of the increasing health care expenditure and constant lack of resources for financing health care services. Health care expenditure (expenditure of the national health insurance fund) increased from 5.6 billion Croatian Kunas (HRK) or US$1.1 billion (US$1=HRK5.2) in 1994 to HRK14.0 billion (or US$2.69 billion, calculated in 1994 US$) in 2000, or 2.5 times in five years (2). According to the Croatian Institute for Health Insurance, the only national health insurance fund, the main reason for the current deficit are the insufficient contributions to the Fund. The number of insured employees (those who pay contributions) is decreasing and the number of those who do not contribute to insurance (dependants, retired, unemployed, and socially vulnerable) is increasing. In 1990, there were 38 retired per 100 employed, and in 1999 there were 74 retired per 100 employed persons (2). Unemployment rate increased to 22% of active population in In that situation, only 33% of the population paid insurance contributions or, in other words, one insured person contributing to insurance fund covered the insurance for himself of herself and two other persons who did not pay contributions. In the last decade, the health care reform in Croatia, as elsewhere in Europe (3-5), was very much a response to the issue of how to contain health care costs in a situation of scarce resources (6-9). A number of measures aimed at cost containment were introduced in the Croatian health care system over the last 10 years, such as rationing of services, limitation of services provided, penalties for excessive over-prescribing or referrals, limited positive drug list, reductions in health care budgets, and increase in co-payments. However, they had limited success and gained little acceptance from both providers and the public (10-13). Macro financial goals of health care reform in Croatia suppressed the issues of the quality of health care services and their response to the needs and expectations of consumers. The reform measures were mostly directed to the supply side (providers), and the demand side measures were not much pronounced, although they were directly or indirectly affecting the consumers. Thus, the growing reduction of public 417

2 health care resources under the reforming health care system, privatization and marketization of services, and increased cost sharing have been shifting a proportion of health care costs on to the health care users, with a significantly negative impact on low income patients (14,15). The new changes in the health insurance system in Croatia, primarily those aimed to restrict patients rights and benefits and to increase private payments, are showing serious impact on the users of health care services. For that reason, it is important to analyze the views of the public on health insurance, to see how the new reform measures correspond to the needs and expectations of the citizens. Our aim was to examine the citizens attitudes toward reforms in health care and health insurance in Croatia. Specifically, we wanted to assess the public opinion on health insurance contributions, changes in the health insurance, and the out-of-pocket payments for health care services. We assumed that the people in Croatia, having enjoyed high and unlimited benefits of social health insurance for a long time and having traditionally a strong perception of health care as a social good, something you get for free, did not have positive attitudes towards the ongoing reforms, which reduce public financing and health care benefits and significantly increase private payments for health care services and pharmaceuticals. We also analyzed views of different demographic and socioeconomic groups on health insurance contributions, health insurance reforms, and private payments for health care, assuming that differences in their opinions would be significant. Subjects and Methods Data were collected through a sample survey carried out in 1999 and 2000 in all regions of Croatia. The questionnaire applied in the study included originally constructed questions about the citizens views on compulsory health insurance and its reform. It also included questions on direct payments for health care services and socio-demographic characteristics of the person surveyed. The respondents were asked to express their agreement or disagreement with the list of statements. The answers were based on a fourdegree scale: completely agree, mostly agree, mostly disagree, and completely disagree. The multistage sample was composed of 500 adults aged 40 and over, randomly selected from households in all regions and from all types of residential areas (metropolitan, ie, Zagreb; urban; semi-urban; and rural). As the first step, in each of the five main regions in Croatia (North-West, North-East, South-West, South-East, and Zagreb) a number of sampling places was drawn at random from the lists of the places of residence. In each of 69 selected sampling places, a starting household was selected at random and further households were selected as every Nth household (address) from the initial address by standard random procedure. In each household, the respondent was drawn at random. The selected adults were face-to-face interviewed in their homes by trained interviewers (medical students). The interviews took 15 minutes on average to be completed. The net response rate was 79%. Major reasons for non-response were absence from home and refusal to be interviewed due to lack of time. The final sample consisted of 393 respondents, 39.2% men and 60.8% women, with the mean age of 51 years (±9.8 SD). Most respondents (81.8%) were younger than 60 years, and 18.2% were aged 60 years and over. Majority were married (76.5%), with a family of four persons on average. The average education level of the respondents was secondary school. The education distribution showed that 54.7% of the respondents had elementary or secondary education, and 45.3% higher education. Most were employed (66.2%), and 25.2% were retired. The occupational status distribution showed that 30.2% were agricultural workers (farmers), unskilled, and skilled workers; 39.2% were routine non-manual employees in administration and commerce; and 30.5% were professionals. The average family income of the respondents was HRK4,000 (or US$500). To analyze the income group differences, the sample was divided into two income groups. The low-income group comprised those with family income of HRK5,000 (US$625) or less (49.6% of the respondents), and the medium-income group had income of HRK5,001 or higher (50.4% of the respondents). Most respondents lived in urban areas (57.3%), 23.4% lived in semi-urban, and 19.3% in rural areas. The results on the citizens views on health insurance contributions, reforms, and out-of-pocket payments for health care were analyzed by sex, age, education, income, occupation, and place of residence. To determine the statistical significance of the differences in the sociodemographic and socioeconomic categorical groups, a chi-square test was used. To analyze the latent dimensions in the citizens views, the principal component model of factor analysis with a VARIMAX rotation was used. For this purpose, only the respondents who expressed positive opinion ( completely agree or mostly agree ) or negative opinion ( mostly disagree or completely disagree ) to the given statements were included in the analysis. The answers to the statements included in the factor analysis ranged from complete agreement to complete disagreement. Differences between sex, age, education, income, occupation, and place of residence were analyzed by comparing the mean values of the factor scores, using t-tests or analysis of variance (ANOVA). The statistical analysis was performed with STATISTICA data analysis software system (Version 6; StatSoft Inc., Tulsa, OK, USA). Results Opinions on Contributions for Health Insurance To analyze the citizens views on health insurance, the respondents were asked questions related to their knowledge on and attitudes toward health insurance contributions (Table 1). Great majority (83.2 %) of the respondents completely or mostly agreed that everybody should have the right to health care irrespective of contributions. The low income group significantly more frequently (59.7%) than the high Table 1. Croatian citizens attitudes on their contributions for health insurance Response (%) How do you feel about the following statement: completely agree mostly agree mostly disagree completely disagree don't know/ no answer Everybody should have the right to health care irrespective of contribution to health insurance Utilization of health care services should depend on health insurance contribution The money you contribute to health insurance corresponds to health care services you receive Persons with higher income should pay higher health insurance rate (contribute more), and persons with lower income should pay lower health insurance rate (contribute less)

3 income group (47.4%) expressed their strong agreement with the universal right to health care irrespective of payments of contributions (chi-square=5.8, p=0.016). One of the problems of the Croatian health insurance fund at the time of the survey was related to irregular payments of contributions. When the respondents were asked whether the actual use of the services should be linked to the payments of contributions, about one third of the respondents (32.1%) agreed with the statement. Opinion distribution by sociodemographic and socioeconomic groups showed that there were significantly more men (chi-square =4.0, p=0.047); those in high income group (chisquare=12.6, p=0.001); and professionals (chisquare=6.5, p=0.011) among respondents who mostly or completely agreed with that statement (Table 2). Those with higher education and from urban areas were also more likely to agree, although not significantly. However, when asked whether higher use of health services should be related to the increase in health insurance contributions, only 17.2% agreed that people who were more frequent users of health care services should pay higher health insurance rate. Table 2. Citizens attitudes on the statement that utilization of health care services should depend on payments of health insurance contributions Social group % of agreement a chi-square p Sex: women men 39 Age: 60 years years 33 Education: lower higher 37 Income: lower higher 41 Occupation: workers professionals 41 Place of residence: urban rural 30 a Percentage of those who completely or mostly agred. We also asked the respondents whether the money they contributed to health insurance corresponded to health care services they received, and about 40% gave positive answer. Approximately the same proportion (30.3%) disagreed or did not know (30.6%). But when asked to estimate how much they contributed monthly from the salary to the compulsory health insurance, only 28.1% could estimate the amount of contribution and most respondents (71.9%) did not know how much their contribution to health insurance was. Significantly more respondents younger than 60 (33.9%) than those older (17.1%) (chi-square=7.5, p=0.006); and significantly more those with high income (36.0%) than those with low income (20.7%) (chi-square=6.1, p=0.048) disagreed that money they paid for health insurance corresponded to health care services they received. As the health insurance financing in Croatia is based on the income-proportional contribution rate, we wanted to know what the respondents thought about the idea of a progressive health insurance rate. A vast majority (60.1%) agreed that the persons with higher income should pay higher health insurance rate (contribute more), and persons with lower income should pay lower health insurance rate (contribute less). Distribution by sociodemographic and socioeconomic groups did not show significant differences, although the respondents with higher education and higher income were more likely to agree with that statement. Reform of Health Insurance Respondents were asked about their attitudes toward changes implemented in the social health insurance system since 1993, when the new law on health insurance was introduced in Croatia. More than half (53.4%) of the interviewed population reported that the current health insurance covered less medical rights (benefits) than in the previous health care system. Only 4.8% of the respondents thought that the present health insurance covered more benefits than 10 years earlier, and 15.8% thought that it was the same as before. Analysis by sociodemographic and socioeconomic groups revealed significant differences in the agreement that the health insurance today covered less benefits than before (Table 3). In general, the respondents with higher education, higher income, and higher occupation status were significantly more likely to share that view. Table 3. Citizens attitudes on the statement that current compulsory health insurance covers less medical benefits compared to 10 years ago Social group % of agreement a chi-square p Sex: women men 61 Education: lower higher 80 Income: low high 78 Occupation: workers professionals 81 Place of residence: urban rural 65 a Percentage of those who completely or mostly agreed. The respondents were further asked about the changes that occurred in the health care and compulsory health insurance system since the introduction of the new health care and health insurance laws (reference period was five years earlier, Table 4). A greater percentage of the respondents (36.9%) agreed that the changes brought more choices, compared with 30.8% of those who disagreed and 32.3% who did not know. High percentage of the respondents (37.7%) also agreed that changes in the health care system and health insurance brought less equity, as compared with those who disagreed (20.8%) with that state- 419

4 Table 4. Citizens attitudes on health insurance reform in Croatia How do you feel about the following statement: Recent changes in health insurance and health care system have brought more choice Recent changes in health insurance and health care system have brought less equity The government should cover health insurance for pensioners, socially vulnerable groups and children through budget revenues It is necessary to define the basic package of health services and to introduce supplementary health insurance Response (%) completely mostly mostly completely don't know/ agree agree disagree disagree no answer ment. Significantly higher percentage of respondents who agreed with the opinion that changes during the last five years brought less equity was found among women (42.8% vs 30.7% men, chi-square=5.7, p=0.017), those with higher education (64.5% vs 42.3% with low education, chi-square=7.6, p=0.022), those with higher income (65.2% vs 48.1% with low income, chi-square=9.3, p=0.001), those with higher occupational status (74.7% vs 57.4% with lower occupational status, chi-square=5.8, p=0.053), and those from urban areas (42.2% vs 32.5% from rural areas, chi-square=3.7, p=0.053). The demand that larger share of the state budget be spent on health care services, specifically for those financially most vulnerable, was examined through agreement with the statement the government should cover health insurance for pensioners, socially vulnerable groups, and children through budget revenues. A large majority of the respondents (90.8%) agreed that the government should spend more from budget for non-paying groups of population. When those who strongly agreed with the statement were analyzed, it was found that significant majority belonged to the low-income group (75.3% vs 60.4% in the high-income group, chi-square=5.8, p=0.053) and group with lower occupational status (74.8% vs 59.8% with higher status, chi-square=3.8, p=0.052). Women (72%) and persons over 60 years of age (75%) were also more likely, but not significantly, to agree with the statement (data not shown). In the following phase of the health insurance reform, the Croatian Government decided to define a basic health insurance package to be covered by compulsory health insurance, and introduce voluntary, supplemental, and private health insurance scheme. The respondents were asked what they thought would be necessary to define and limit the proportions of the health care services costs to be covered by compulsory health insurance (the basic health insurance package) and leave the difference in costs and all other excluded services or the amenities to be covered by supplementary insurance. The percentage of those who disagreed (46.0%) was higher than those who agreed (42.5%) with the limitation of health care service covered by compulsory health insurance. Analysis by sociodemographic and socioeconomic groups showed that those who disagreed with the restriction of basic package were respondents aged 60 years and over (chi-square=5.8, p=0.053), those with low income (chi-square=5.7, p=0.017), and low occupational status (chi-square= 6.6, p=0.010). Women, those with low education, and from rural areas were more likely to disagree, but not significantly (Table 5). On the contrary, those who agreed with the limitation of basic package and introduction of supplementary insurance were significantly more likely to be younger, with high income, and from higher occupational group. Only a small proportion of the respondents reported having a supplementary (privately paid) health insurance (6.9%) although the legal provision for that kind of voluntary insurance had been introduced as early as Table 5. Disagreement of citizens with the introduction of basic package of health services and supplementary insurance Social group % of disagreement a chi-square p Sex: women men 44 Age: 60 years years 59 Education: lower higher 51 Income: lower higher 46 Occupation: workers professionals 43 Place of residence: urban rural 54 a Percentage of those who completely or mostly disagreed. Private Payments and Inequalities in Access To examine the public views on private payments for health care, the respondents were asked how much out-of-pocket money they spent for health care during the previous 12 months (Table 6). More than half (56.5%) of the respondents reported having small expenses and 35.5% reported having large or very large expenses. There were no significant differences between social groups although those with lower education (37.5%), lower income (38.2%), and lower occupational status (36.2%) were more likely to report having large or very large expenses, compared with those with high education, high income, and high occupational status. When asked about their perception of private payments, a large proportion of respondents (45.8%) held the opinion that they were paying too much from their own pocket for health care. Analysis of the sociodemographic and socioeconomic group differ- 420

5 Table 6. Citizens views on private payments for health care in Croatia Question Response % What would you say, how much did you spend out of your pocket I did not have any expenses 8.0 for health care during the past 12 months? I had small expenses 56.5 I had large expenses 28.9 I had very large expenses 6.6 What do you think, do the citizens pay for health care too much Yes, too much has to be paid from one's 45.8 out of pocket or not? own pocket for health care It is tolerable 37.8 A little 6.0 Don't know 10.4 If you need immediate health care services, as for example surgery or special I should pay out of my pocket 35.1 diagnostic procedures, can you get it without paying out of your own pocket? I should not pay 29.1 Don't know 35.8 How do you agree with the statement that "some people in our country have Completely agree 44.3 easier access to health care services and receive better quality of care than others"? Mostly agree 38.0 Mostly disagree 5.5 Completely disagree 2.6 Don't know 9.6 Table 7. Croatian citizens who believe they should pay out of the pocket when in need of immediate health care services Social group % chi-square p Sex: women men 62 Age: 60 years years 58 Education: lower higher 46 Income: lower higher 44 Occupation: workers professionals 44 Place of residence: urban rural 72 ences showed that those who agreed were mostly respondents from low-income group (51.8% vs 35.0% with high income, chi-square=9.7, p=0.008), those with lower occupations (59.6% vs 35.7% with higher occupations, chi-square=12.7, p=0.002), and more likely, but not at a significant level, those with low education and from rural areas. The respondents were further asked whether they could receive immediately needed health care services without paying out of their own pocket, for example, surgery or special diagnostic procedures, and 35.1% of the respondents reported that if they needed health care services without delay, they would have to pay out of their pocket. When analyzed by social group, it was found that significantly more respondents with lower education (chisquare=4.7, p=0.030), lower income (chi-square= 10.4, p=0.001), lower occupational status (chisquare=5.1, p=0.024), and from rural areas (chisquare=21.4, p<0.001) believed that when in need of prompt health care services they would have to pay for it (Table 7). The respondents were asked to assess the social inequalities regarding access to health care services. A large majority of respondents (82.3%) agreed that some people had easier access to health care services and received better care than others. Significantly more likely to strongly agree that there existed social inequalities in access to health care services were respondents with lower education (51.5% vs 36.2% with higher education, chi-square=8.5, p=0.004), low income (49.5%, chi-square=4.5, p=0.034), and from rural areas (50.6% vs 39.5% urban, chisquare=4.7, p=0.031). Underlying Dimensions in Citizens Opinions on Health Insurance (Factor Analysis) To identify the underlying dimensions in citizens opinions on health insurance and payments for health care services, the factor analysis was performed. Ten variables reflecting the attitudes of the respondents were used for the factor analysis: A1 Everybody should have the right to health care, irrespective of contribution to health insurance; A2 Utilization of health care services should depend on health insurance contribution; A3 The money you contribute to health insurance corresponds to health care services you receive; A4 Compared to 10 years ago, current compulsory health insurance covers less medical benefits; A5 Recent changes in health insurance and health care system have brought more choice; A6 Recent changes in health insurance and health care system have brought less equity; A7 It is necessary to define the basic package of health services and to introduce supplementary health insurance, A8 Assessment of own expenses for health care; A9 Citizens pay for health care too much out of pocket; and A10 Some people have easier access to health care services and receive better quality of care than others. Answer categories ranged from complete agreement to complete disagreement, except for the assessment of own health care expenses where the answers were no expenses, small, tolerable, and large or very large expenses. Three latent dimensions with eigenvalue above 1.0 were obtained by factor analysis (Table 8). They accounted for 51.7% of the total variance. Communalities of all three principal components were >0.4. The first factor (eigenvalue 2.651) was recognized as negative opinion on changes in health insurance, with the highest loadings of for attitudes A6, A4, A5, and A8. This factor was predominantly 421

6 described by agreement that recent changes brought less equity (A6) and that current health insurance covers less benefits than 10 years ago (A4), disagreement that recent changes brought more choice (A5), and assessment of own direct expenses for health care as large or very large (A8). The second factor (eigenvalue 1.290) could be interpreted as the affirmative assessment of changes in health insurance, with the highest loadings of for attitudes A10, A9, A3, and A5. The second factor was predominantly defined by disagreement that some people have easier access to health care services and receive better quality of care than others (A10), followed by assessment that citizens pay small amount out of pocket for health care (A9), and opinion that health insurance contributions correspond to health care received (A3). It could also be defined by the opinion that recent changes brought more choice (A5). The third factor (eigenvalue 1.231) could be recognized as universal health care services, with the highest loadings of for attitudes A2, A1, and A7. That factor was described by disagreement that use should depend on payments of contributions (A2), followed by agreement that everybody should have right to health care irrespective of paying contributions (A1), and disagreement that it is necessary to introduce basic package of health services and supplementary health insurance (A7). The differences in principal components regarding sex, two age groups, and place of residence were analyzed by a t-test. There were no significant differences between men and women, younger and older (over 60 years), and urban and rural respondents in any of the three factors. The differences between education, income, and occupational groups were analyzed by ANOVA. The analysis revealed that three education groups were not significantly different. The income groups differed significantly in all three factors: negative opinion on changes in health insurance (F=4.30, p=0.016), affirmative assessment of changes in health insurance (F=3.29, p=0.041) and universal health care services (F=3.99, p=0.021). Scheffe s multiple comparison tests (p<0.05 significance level) revealed that low- and medium-income groups were responsible for differences in the first factor, the high income group was responsible for differences in the second factor, and the medium income group was responsible for the differences in the third factor. The occupational groups significantly differed only in the first factor (F=8.063, p=0.001), with the low occupational group responsible for the difference. Discussion This study showed that Croatian citizens highly supported the universal health services, regardless of insurance contribution payment. They strongly believed that health care is a social good to which everybody have a right, and not a market commodity that could be sold and bought. This may be seen as a result of a long tradition of the former socialist, stateregulated social health insurance. However, it seems that although the majority thought that health care should be universally accessible, about one third agreed that the use of services should depend on payments. More citizens believed that health care services they received corresponded to their contributions, and a large majority supported the idea of progressive contribution rates. The reform of the health care system that has been taking place in Croatia over the past 10 years has significantly affected the position of citizens as patients and increased their dissatisfaction (13-15). According to the opinion of the majority of citizens included in this study, the patients benefits in the existing health insurance were reduced in comparison to 10 years ago. More than one third believed that changes brought more choice, and a similarly large but different social group believed that changes brought less equity. The interviewed Croatian citizens strongly supported the demand that government should increase spending for health care services through state budget revenues and thus take financial responsibility for health care of non-paying groups of population, such as the retired, unemployed, children, and other socially vulnerable groups. The most important change in the recent health insurance reform, the introduction of the basic health insurance package with limited value of benefits and implementation of the supplementary insurance scheme, divided the citizens, who more disagreed than agreed with this change. Privatization and marketization of services under the health care reform significantly increased citi- Table 8. Correlation coefficients among the survey variables and underlying factors Varimax rotation with Kaiser normalization Variable Factor symbol description 1 a 2 b 3 c A6 recent changes brought less equity A4 current health insurance covers less benefits than before A5 recent changes brought more choice A8 assessment of own expenses for health care A10 some people have easier access to health care services A9 citizens pay for health care too much out of pocket A3 contributions correspond to received health care A2 utilization should depend on contribution A1 right to health care irrespective of contribution A7 necessary to introduce basic package of health services and supplementary health insurance Eigenvalue Variance (%) Cumulative (%) a Negative opinion on changes in health insurance. Affirmative assessment of changes in health insurance. Universal health care services. 422

7 zens out-of-pocket spending on health care, as evidenced in this study. There is a strong public belief that health care services are not equally accessible to all and that out-of-pocket payments can make the access easier. In general, the higher socioeconomic groups, those under 60 years of age, men, and respondents from urban areas expressed more criticism in their views (less benefits, less equity) and agreed with the cost-containment measures. The lower socioeconomic groups, those over 60 years of age, women and rural respondents were positively oriented towards universal access, state health care financing, and mostly disagreed with the introduction of basic health insurance package. However, more research is necessary to analyze the impact of health insurance reform from the perspective of different social groups. Three underlying dimensions in citizens views revealed by the factor analysis were negative opinion on changes in health insurance, significant for those with low- and medium-income and low occupational status; affirmative assessment of changes in health insurance, significant for the high-income group; and universal health coverage, significant for the medium-income group. Using survey data, we examined the public perception of the existing social health insurance in Croatia and of the changes taking place under the reform. In the study sample, the adults over 40 years of age were selected, with the idea to address those who used health care services more frequently and were better informed. There were certain limitations concerning the sample, with over-represented sociodemographic group of women, those with higher education, higher family income, and from urban areas. Previous studies showed that there was no consistent association between socioeconomic characteristics and attitudes towards health care services (16,17), although it was found that older people tended to have more positive attitudes (less expectations), and that higher-education and higher-income people were more ready to criticize and have negative attitudes (higher expectations) (18,19). Accordingly, it could be assumed that a more representative sample in this study would show more positive attitudes and higher degree of agreement. Other limitations that could have affected our results concerned the problems occurring in public opinion surveys in general, such as the structure of questions, cognitive bias, survey duration, or media influences (20,21). The survey was carried out in 1999 and 2000, two years before the actual change of health insurance legislation, at the time when the discussion on insurance reform started. Different policy measures were discussed in professional associations and in the public, yet not all were tested in this opinion survey. Some of those evaluated, however, did not happen to be implemented by the new law. Most of the reforms that have been taking place in the Croatian health care system in the last 10 years were directed towards the supply side, targeting first of all providers of services. Those reform measures that aimed to reduce the demand of services with the influence on the consumers, such as the introduction of co-payments, resulted in high dissatisfaction of consumers and increased inequalities in health care financing (13,15). Until recently, however, the changes have not significantly affected the health insurance benefits of the insured, which remained comprehensive and fully covered. With the new Health Insurance Act of October 2001 (22), the government decided to solve the financial problems in health insurance fund by introducing basic health insurance as compulsory, and supplementary and private health insurance scheme. In the basic health insurance package, financing is reduced from 85% to 50% of the total service price in specialist and hospital care, and from 75% to 25% of costs for medicaments. Preventive and primary health care services are fully covered. In addition to basic, supplementary insurance is established to cover the difference between the basic insurance and the total service cost, and for amenities or services not covered by basic insurance. If not through voluntary supplementary insurance, patients have to pay the uncovered proportion of the total service price by cost sharing (co-insurance). Exemptions are made in regulations for those with the defined minimal income per person. Under the new health insurance law, the financing has been reduced to the basic health insurance package, which covers benefits limited in money value. The insured are required to pay privately significantly higher proportions of the cost of services (co-insurance) or to purchase supplementary insurance to cover expenses not included in the basic insurance package. Against this background, we assumed that it was important to analyze the views of the public, since the new health insurance reform had serious impact on the citizens. To take a proper account of the views and feelings of the general public in the process of developing and implementing health policy is particularly important, having in mind the main objectives of the reformers to meet the citizens needs (23). The study of the public opinion on the health reform is a valuable tool for testing how the implemented measures correspond with the citizens expectations. It is also an input for developing future health policy and establishing priorities in health care system. Although there were some attempts to analyze health insurance and its changes in the countries in transition (24-29), the reforms were rarely evaluated from the citizens perspective (13-15). The reasons may be found partly in the skepticism about the usefulness of opinion surveys for health policy and in methodological and other survey-related difficulties (30,31). However, the evidence on citizens views on health care reforms in the European Union countries suggests a positive impact of the public evaluation approach to reform s issues (32-34). The citizens in Croatia are presently expressing their concerns with the undergoing health insurance reform. They mostly support the principle of the universal health care services, with the government responsibility for providing it to all citizens, and do not agree with rationing of benefits and implementation of market mechanisms into the Croatian social health 423

8 insurance. At the time of significant changes, to have an insight into the views of the public can be valuable for policy-makers, providing them with citizens perceptions of the implemented measures and policy options. If the goal of the health reform is to create a system more responsive to citizens needs and expectations, knowledge of the public s demands should be taken into account. Acknowledgments This research was a part of the project Evaluation of Transition in Health Care, supported by the Central European Network collaborative program for research and education in health sector. We thank the medical students who served as interviewers. References 1 Ministry of Health, Republic of Croatia. Health care reform. Strategy and plan for the reform of the health care system and health insurance of the Republic of Croatia [in Croatian]. Zagreb: Croatian Ministry of Health; Croatian Institute for Health Insurance. Annual audit report of Croatian Institute for Health Insurance and Croatian Health System, 2000 financial plan and basic management propositions for Zagreb: Croatian Institute for Health Insurance; Organization for Economic Co-operation and Development. The reform of health care systems: a review of seventeen OECD countries. Washington (DC): OECD; Vienonen M. Overview of the principles in health care reforms on the European scene. Antidotum Supplement 1995;1: World Health Organization, Regional Office for Europe. European health care reforms: analysis of current strategies. Copenhagen: WHO; Saltman RB, Figueras J, editors. European health care reform. Analysis of current strategies. Copenhagen (Denmark): WHO Regional Publication; European Series, No. 72; Abel-Smith B, Mossialos E. Cost containment and health care reform: a study of the European Union. Health Policy 1994;28; Maarse H. Cost containment in health care: a brief overview. Antidotum Supplement 1995;1: Mossialos E, Le Grand J, editors. Health care and cost containment in the European Union. Aldershot (UK): Ashgate; Hebrang A. Reorganization of the Croatian health care system. Croat Med J 1994;35: Oreškoviæ S. Health system reorganization in Croatia in the light of major reform tendencies in OECD countries. Croat Med J 1995;36: Kovaèiæ L, Šošiæ Z. Organization of health care in Croatia: needs and priorities. Croat Med J 1998;39: Mastilica M, Chen M. Health care reform in Croatia: the consumers perspective. Croat Med J 1998;39: Chen M, Mastilica M. Health care reform in Croatia: for better or for worse? Am J Public Health 1998;88: Mastilica M, Bo ikov J. Out-of-pocket payments for health care in Croatia: implications for equity. Croat Med J 1999;40: Fox JG, Storms DM. A different approach to sociodemographic predictors of satisfaction with health care. Soc Sci Med [A] 1981;15: Fitzpatrick R. Survey of patient satisfaction: I important general considerations. BMJ 1991;302: Hall JA, Dornan MC. Patient sociodemographic characteristics as predictors of satisfaction with medical care: a meta-analysis. Soc Sci Med 1990;30: Sitzia J, Wood N. Patient satisfaction: a review of issues and concepts. Soc Sci Med 1997;45: Blalock HM, Blalock AB, editors. Methodology in social research. 2nd ed. London: McGraw-Hill Inc.; Judge K, Solomon M, Miller D, Philo G. Public opinion, the NHS, and the media: changing patterns and perspectives. BMJ 1992;304: Croatians Parliament. Health insurance act [in Croatian]. Narodne novine 94/ Mossialos E. Citizens and health systems: main results from a Eurobarometer survey. Luxembourg: European Commission; Kersnik J. Determinants of customer satisfaction with the health care system, with the possibility to choose a personal physician and with a family doctor in a transition country. Health Policy 2001;57: Turek S. Reform of health insurance in Croatia. Croat Med J 1999;40: Ljubiæ B, Hrabaè B, Rebac Z. Reform of health insurance in the Federation of Bosnia and Herzegovina. Croat Med J 1999;40: Donev D. Health insurance system in the Republic of Macedonia. Croat Med J 1999;40: Markota M, Švab I, Sara in-klemenèiæ K, Albreht T. Slovenian experience on health care reform. Croat Med J 1999;40: Field MG. Reflections on a painful transition: from socialized to insurance medicine in Russia. Croat Med J 1999;40: Mechanic D. Public perceptions of medicine. N Engl J Med 1985;312: Al-Swwailem AF. Should opinion polls be more widely used in developing countries? Health Policy Plan 1991;6: Pescosolido BA, Boyer CA, Tsui WY. Medical care in the welfare state: a cross-national study of public evaluations. J Health Soc Behav 1985;26: Blendon RJ, Leitman R, Morrison I, Donelan K. Satisfaction with health systems in ten nations. Health Aff (Millwood) 1990;9: Mossialos E. Citizens views on health care systems in the 15 member states of the European Union. Health Econ 1997;6: Received: March 6, 2002 Accepted: June 12, 2002 Correspondence to: Miroslav Mastilica Department of Medical Sociology Andrija Štampar School of Public Health Zagreb University School of Medicine Rockefellerova Zagreb, Croatia mmastil@andrija.snz.hr 424